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A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin
  1. Edward W Carlton1,2,
  2. Louise Cullen3,
  3. Martin Than4,
  4. James Gamble5,
  5. Ahmed Khattab1,
  6. Kim Greaves6
  1. 1Bournemouth University, Centre of Postgraduate Medical Research & Education, Faculty of Health and Social Sciences, UK
  2. 2Poole Hospital NHS Foundation Trust, Dorset, UK
  3. 3Emergency Department, Royal Brisbane and Women's Hospital, Queensland, Australia
  4. 4Emergency Department, Christchurch Hospital, New Zealand
  5. 5Department of Cardiology, John Radcliffe Hospital, Oxford, UK
  6. 6Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Queensland, Australia
  1. Correspondence to Dr Edward Carlton, Department of Cardiology, Poole Hospital NHS Foundation Trust, Longfleet Road, Poole, Dorset BH15 2JB, UK; eddcarlton{at}gmail.com

Abstract

Objective To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We also compared the diagnostic accuracy of this ADP with strategies using initial undetectable hs-cTnT.

Methods This prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14 ng/L, a non-ischaemic ECG and a modified Goldman risk score. Diagnostic performance of the ADP was compared with the detection limit cut-offs of hs-cTnT (<5 ng/L and <3 ng/L). The primary end point was fatal/non-fatal acute myocardial infarction (AMI) within 30 days.

Results 960 participants were recruited, mean age 58.0 years, 80 (8.3%) had an AMI. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying AMI of 98.8% (95% CI 92.5% to 99.9%). hs-cTnT detection limits (<5 ng/L and <3 ng/L) had a sensitivity of 100% (94.3 to 100) and 100% (94.4 to 100), respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5 ng/L) and 7.9% (<3 ng/L) (p<0.001) with a lower false-positive rate for AMI detection; specificity 43.3% (95% CI 42.7% to 43.4%) vs 32.0% (95% CI 31.5% to 32.0%) and 8.6% (95% CI 8.1% to 8.6%), respectively.

Conclusions The TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies.

Trial registration number ISRCTN No. 21109279.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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